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Earned Placement: Damon Ultima System by Dr. Michael Bicknell

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Categories: Orthodontics;
Earned Placement: It’s About Time 

Leveraging innovative technologies and phase-based protocols in a Class 2 case can restore the most valuable asset we have: time!

by Dr. Michael Bicknell

In today’s rapidly changing world, using new and emerging technologies has profoundly changed how we experience and value time. These innovations have significantly affected various aspects of our lives, showcasing that time is our most precious resource.

A prime example of this can be seen in the Damon Ultima System, a cutting-edge technology in the field of orthodontics. This system uses a novel wire-bracket interface that controls teeth in all three planes of space, allowing orthodontists to reach the end result more efficiently and effectively (Figs. 1 and 2). This system not only represents a leap forward in orthodontic treatment but also highlights how emerging technologies can make the most of everyone’s time.
Earned Placement: Damon Ultima System
Fig.1: The foundation of the Damon Ultima System is a design that uses a proprietary round-sided rectangular wire and a parallelogram-shaped slot that delivers direct engagement at vertical and horizontal contact points.

Earned Placement: Damon Ultima System
Fig. 2: The design also incorporates a center slot lineup that allows for predictable vertical expressed position when using selective variable torque brackets.


By blending the new advancements with the protocols developed to make maximum use of the product’s engineering, we have unlocked unprecedented efficiency, connectivity to our patients and personal empowerment of our teams in our practice. This continues to streamline patient care to deliver the ultimate patient experience.

The following discussion will showcase the treatment of a routine patient with a commonly seen malocclusion. The goals are to illustrate how innovative technology and phase-based treatment stages can be merged to deliver revolutionary efficiency and highly reproducible aesthetic finishes with fewer wire bends. It will also show overall ease of treatment that has the potential to improve our daily practice lives drastically. This all occurs by giving back the most valuable asset orthodontists, orthodontic teams and our patients have—time.

Case study
Diagnosis
A 13-year-old male patient presented with a Class 2 malocclusion with mild maxillary and mandibular crowding (Figs. 3a–3d). The facial profile was convex with a slightly retrusive mandible because of a vertical mandibular pattern. Normal lip strictures were noted with slight strain on closure because of the vertical growth pattern. A constricted arch form with tapered buccal segments resulted in poor smile width and dark buccal corridors. This, along with multiple vertical height discrepancies and open incisal embrasures, resulted in poor smile aesthetics.
Earned Placement: Damon Ultima System
Fig. 3a
Earned Placement: Damon Ultima System
Fig. 3b
Earned Placement: Damon Ultima System
Fig. 3c
Earned Placement: Damon Ultima System
Fig. 3d


Objectives/plan
The objectives for the maxillary arch were to develop the arch, create space for the maxillary anterior teeth, and maintain the vertical and A-P position and angulation of the incisors. The mandibular objectives were posterior buccal uprighting, leveling the curve of Spee, and advancing lower incisors while controlling facial angulation for an ideal result. A nonextraction plan was chosen using the Damon Ultima System, along with the use of light Class 2 elastics overbite correction.

Case setup
The brackets chosen were Damon Ultima PSL variable torque brackets. Because of the need for maxillary arch development and the plan to use Class 2 elastics, proclined torques were used on the maxillary anterior to protect the facial angulations from the unwanted lingual tipping predicted with both arch development and Class 2 elastics. In the mandibular arch, the lower canines required uprighting; therefore, proclined brackets were used and retroclined were used on the L2–2 to protect lower incisor angulation against the proclining forces of arch leveling and resultant forces of Class 2 elastics (Fig. 4).
Earned Placement: Damon Ultima System
Fig. 4

All permanent teeth were bonded except for the UR3, where a nickel titanium (NiTi) coil spring activated 2 mm was placed to create space for eruption. Initial wires, 0.014-inch copper nickel titanium (CuNiTi), were placed in both arches; the bite was disarticulated, and 2-ounce, 3/16-inch elastics started from the U4s to the L6s full-time, and a referral was provided to have Tooth C removed.


Case progression
Phase 1 (0–7 months)
Bracket placement was positioned in a normal bonding protocol around FA point with the U1s at 5.5 mm from the incisal edge to the bracket slot. Initial 0.014 CuNiTi U/L and an early elastic were started using 2-ounce, 3/16-inch Class 2 elastics from the U4s to the L6s to support the open coil spring, as well as the correction of the Class 2. It is important to note that if the lower arch had moderate crowding, elastics would have been delayed until the crowding was resolved through posterior development to prevent unwanted round-tripping of the lower anterior teeth.

After six weeks, the patient returned and the UR3 was engaged while maintaining U/L archwires. The patient was seen again after six more weeks, and wires were changed to 0.018-inch CuNiTi extending to the U/L 7s. Wires were again changed six weeks later to 0.014-by-0.0275-inch CuNiTi Ultima U/L. These were maintained for eight weeks until the patient returned for his Phase 1 evaluation (Fig. 5).
Earned Placement: Damon Ultima System
Fig. 5

Observations: Because the Damon Ultima System was designed to be a true full-expression system, consistent attributes are seen throughout treatment. At the end of this phase, all rotations are expected to be resolved, maxillary arch development is seen along with mandibular buccal uprighting and axial inclinations are almost set. All are seen here with the maxillary arch development resulting in a 3 mm diastema and a significant improvement in the Class 2 buccal relation. There were only two simple archwire changes, and this portion of the treatment was completed in about 7 months.

Phase 2 (7–10 months)
Upon returning, the wires were changed to 0.018-by-0.0275-inch CuNiTi Ultima U/L. A Generation 2 wide chain was placed from the U3–3 to consolidate the anterior spacing, and the elastics were changed to 3.5-ounce, 3/16-inch (rabbit) Class 2 full-time. A few brackets were repositioned at the six-week pan/repo appointment, and the case was left for an additional six weeks (Fig. 6) before progressing to the final wires.
Earned Placement: Damon Ultima System
Fig. 6

Observations: One of the most remarkable attributes of the Damon Ultima System is that when using variable torque brackets, the 0.018-by-0.0275-inch wire has full control in all three planes of space, and first, second and third orders of tooth movement are fully expressed and controlled. When using light intermaxillary elastics (2 ounces), the resultant forces are expressed in the anterior-posterior direction but not so strong as to overpower the torque couples protecting the incisor facial angulations. Additionally, once the tooth movement has been expressed, the wire-bracket interaction becomes passive.

At the end of this phase, all corrected rotations are expected to be maintained, axial inclinations are corrected, and anterior torque is fully expressed and protected. Again, the predictability of this system is seen in these Phase 2 photographs. Phase 2 is one of the most straightforward in that it consists of one archwire change, and the overall time is an additional three months, moving the total treatment time to 10 months.

Phase 3 (10–13 months)
The final wires chosen in this case were 0.018-by-0.0275-inch stainless steel (SS) Ultima upper and 0.016-by-0.0275-inch SS Ultima lower. The reason for the SS wires was to have the proper stiffness to allow for space closure between the anterior and posterior segments using a 125 g, 12 mm NiTi coil spring and archwire shaping for added arch development. The lower SS wire was used for continued buccal uprighting and final arch leveling. The patient was seen for two visits for shaping of wires, slight enamel reshaping and continued Class 2 settling elastics to achieve ideal occlusion before removal.

Observations: Photos taken at the end of Phase 3 (Fig. 7) are one week before removal. Seeing that all items on the original problem list should be resolved, this is a quick appointment where everything is checked; a scan is taken for our lab-fabricated L3–3 and photos are taken. We are trying to avoid any issues that would prevent our patients from being anything but thrilled on the day the braces are removed.
Earned Placement: Damon Ultima System
Fig. 7

Because this bracket-archwire interaction eliminates the problem of “bracket-wire play,” we are finishing most of our cases with almost no wire bending. The last phase of treatment is also very straightforward because all the teeth will be in the proper positions, with the last archwire change and time left being based on the patient’s occlusal requirements. In this case, Phase 3 lasted an additional three months.


Case completion
The retention plan included direct placement of an upper 2112 braided SS fixed retainer and a digital scan for U/L Essix retainers with a custom-made 0.025-by-0.019-inch gold fixed retainer bonded to the L3–3. Retainers were provided along with tooth whitening gel with instructions for full-time wear for one week, then nights only.


Overview
An overview of the case (Figs. 8a– 8d) illustrates a beautiful result in all anterior aesthetics, posterior arch development and functional occlusion. By leveraging the advanced technology and engineering of the Damon Ultima PSL system, selecting variable torque brackets and using refined phase-based protocols, we were able to treat this case to a wonderful result in a short period of time. Maxillary incisor position and angulation were maintained even with significant arch development and Class 2 elastics, illustrating the torque control of this system. Overall, the patient was highly compliant with elastics from the beginning to the end of treatment.
Earned Placement: Damon Ultima System
Fig. 8a
Earned Placement: Damon Ultima System
Fig. 8b
Earned Placement: Damon Ultima System
Fig. 8c
Earned Placement: Damon Ultima System
Fig. 8d


From a clinical efficiency standpoint, the patient had nine treatment visits completed in less than 13 months.

When looking at the total treatment time, this case was treated in a timeline that was unthinkable to our practice just a short time ago. From the ease of appointments for both the patient and the team to the reduced treatment visits and overall time, it demonstrates that this technology can drastically shift how we think and treat patients. The most significant advantage when looking past the beautiful and functional result is saving time for the orthodontist, the orthodontic team and the patient.

Author Bio
Dr. Michael Bicknell Dr. Michael Bicknell graduated from the University of Illinois Chicago as valedictorian of his doctorate class and later joined the orthodontic faculty as a clinical instructor. Bicknell’s multilocation private practice, Advanced Orthodontic Specialists, is in the Chicago suburbs, and his educational messages have been presented at speaking events in more than 14 countries. He is the co-founder of the Ultimate Orthodontic Academy, an online and in-office platform that provides educational courses for orthodontic professionals, students and teams. Bicknell is also a Damon System Mentor and a paid consultant for Ormco.
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